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Combined granulomatous and lymphocytic hypophysitis presenting as pituitary incidentaloma in a middle-aged woman.

Gundgurthi A, Kharb S, Garg MK, Brar KS, Bharwaj R, Gupta S, Pathak HC - Indian J Endocrinol Metab (2012)

Bottom Line: She had normal pituitary function and visual perimetry.Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin.As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

View Article: PubMed Central - PubMed

Affiliation: Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, India.

ABSTRACT
We report a case of 41-year-old lady who presented with chronic headache of 6-month duration and a sellar mass with a suprasellar extension on imaging, which was interpreted as pituitary macroadenoma. She had normal pituitary function and visual perimetry. On clinical examination and imaging it was provisionally diagnosed as pituitary incidentaloma due to hypophysitis and she was advised steroid therapy, but underwent transnasal resection of the tumor against suggestion. Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin. Definitive diagnosis of hypophysitis can be made only on histopathological examination. As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

No MeSH data available.


Related in: MedlinePlus

(a) Preoperative image showing 1.78 × 1.12 × 2.2 cm lesion, homogenously hyperintense on T1W postcontrast image, showing thickening of pituitary stalk and dural tail. (b) Postoperatively normal sella with no residual lesion
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Figure 1: (a) Preoperative image showing 1.78 × 1.12 × 2.2 cm lesion, homogenously hyperintense on T1W postcontrast image, showing thickening of pituitary stalk and dural tail. (b) Postoperatively normal sella with no residual lesion

Mentions: Her hematological and biochemical work-up was normal barring erythrocyte sedimentation rate (ESR) which was 54 mm at the end of first hour. Her hemoglobin was 14 g/ dl; total leucocyte count was 6700/μl, neutrophil count of 64%, lymphocyte count of 30%, monocyte 4%, eosinophil 2%; fasting plasma glucose 92 mg/dl, blood urea 22 mg/ dl, serum creatinine 0.6 mg/dl, serum bilirubin 0.5 mg/dl, ALT-6IU/l, ALP 32 IU/l, serum alkaline phosphatase 86 U/l, serum calcium 8.5 mg/dl, serum phosphates 3.4 mg/dl. She had normal hormonal work-up (fT3 – 3.4 pg/ ml [2.4-4.2], fT4 – 1.4 ng/ ml [0.8-1.7], TSH – 3.56 [0.5- 6.5] μIU/ml; LH/FSH – 7.8/9.4 IU/l; S. estradiol– 75 pg/ml; S. prolactin – 14 ng/ml [< 25]; S. Cortisol basal/ACTH stimulated – 14 /23.6 μg/dl). The Mantoux test was strongly positive (20×55mm). Chest radiography, 2D echocardiogram, ultrasound abdomen were normal. Serum angiotensin convertase enzyme was 39.0 U/l (8-65). Autoimmune workup did not reveal any abnormality with CRP – 1.2 mg/l (normal < 7 mg/l); antinuclear antibodies (< 1:40), and antineutrophilic cytoplasmic antibodies (< 1:16), anti-TPO Ab - 4 IU/l (< 9), RA factor 4 IU/l (< 20), and anti-TTG Ab- 3.54 IU/ ml (< 15). CT scan of chest and abdomen was normal. A review of MRI brain favored hypophysitis more than pituitary adenoma in view of homogeneity of the mass, thickened and midline pituitary stalk, strong and diffuse enhancement after contrast, and loss of posterior pituitary hyper intensity and maintenance of sellar floor [Figure 1]. The possibility was discussed with the patient and close observation with steroid therapy was contemplated.


Combined granulomatous and lymphocytic hypophysitis presenting as pituitary incidentaloma in a middle-aged woman.

Gundgurthi A, Kharb S, Garg MK, Brar KS, Bharwaj R, Gupta S, Pathak HC - Indian J Endocrinol Metab (2012)

(a) Preoperative image showing 1.78 × 1.12 × 2.2 cm lesion, homogenously hyperintense on T1W postcontrast image, showing thickening of pituitary stalk and dural tail. (b) Postoperatively normal sella with no residual lesion
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3475921&req=5

Figure 1: (a) Preoperative image showing 1.78 × 1.12 × 2.2 cm lesion, homogenously hyperintense on T1W postcontrast image, showing thickening of pituitary stalk and dural tail. (b) Postoperatively normal sella with no residual lesion
Mentions: Her hematological and biochemical work-up was normal barring erythrocyte sedimentation rate (ESR) which was 54 mm at the end of first hour. Her hemoglobin was 14 g/ dl; total leucocyte count was 6700/μl, neutrophil count of 64%, lymphocyte count of 30%, monocyte 4%, eosinophil 2%; fasting plasma glucose 92 mg/dl, blood urea 22 mg/ dl, serum creatinine 0.6 mg/dl, serum bilirubin 0.5 mg/dl, ALT-6IU/l, ALP 32 IU/l, serum alkaline phosphatase 86 U/l, serum calcium 8.5 mg/dl, serum phosphates 3.4 mg/dl. She had normal hormonal work-up (fT3 – 3.4 pg/ ml [2.4-4.2], fT4 – 1.4 ng/ ml [0.8-1.7], TSH – 3.56 [0.5- 6.5] μIU/ml; LH/FSH – 7.8/9.4 IU/l; S. estradiol– 75 pg/ml; S. prolactin – 14 ng/ml [< 25]; S. Cortisol basal/ACTH stimulated – 14 /23.6 μg/dl). The Mantoux test was strongly positive (20×55mm). Chest radiography, 2D echocardiogram, ultrasound abdomen were normal. Serum angiotensin convertase enzyme was 39.0 U/l (8-65). Autoimmune workup did not reveal any abnormality with CRP – 1.2 mg/l (normal < 7 mg/l); antinuclear antibodies (< 1:40), and antineutrophilic cytoplasmic antibodies (< 1:16), anti-TPO Ab - 4 IU/l (< 9), RA factor 4 IU/l (< 20), and anti-TTG Ab- 3.54 IU/ ml (< 15). CT scan of chest and abdomen was normal. A review of MRI brain favored hypophysitis more than pituitary adenoma in view of homogeneity of the mass, thickened and midline pituitary stalk, strong and diffuse enhancement after contrast, and loss of posterior pituitary hyper intensity and maintenance of sellar floor [Figure 1]. The possibility was discussed with the patient and close observation with steroid therapy was contemplated.

Bottom Line: She had normal pituitary function and visual perimetry.Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin.As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

View Article: PubMed Central - PubMed

Affiliation: Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, India.

ABSTRACT
We report a case of 41-year-old lady who presented with chronic headache of 6-month duration and a sellar mass with a suprasellar extension on imaging, which was interpreted as pituitary macroadenoma. She had normal pituitary function and visual perimetry. On clinical examination and imaging it was provisionally diagnosed as pituitary incidentaloma due to hypophysitis and she was advised steroid therapy, but underwent transnasal resection of the tumor against suggestion. Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin. Definitive diagnosis of hypophysitis can be made only on histopathological examination. As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

No MeSH data available.


Related in: MedlinePlus